Realist Approach to Social Policies (RASP) study to reduce socioeconomic health inequalities through systems change: protocol for a research project combining mixed-methods realist research with institutional action research

Introduction Health inequalities are rooted in inequality in vital resources for health, including financial resources, a supportive informal network, a stable living situation, work or daytime activities or education and literacy. About 25% of Dutch citizens experience deprivation of such resources. Social policy consists of crucial instruments for improving resources in those groups but can also have adverse effects and lead to additional burdens. This project aims to contribute to the reduction of health inequalities through (1) a better understanding of how social policy interventions can contribute to reducing health inequality through the redistribution of burdens and resources and (2) developing anticipatory governance strategies to implement those insights, contributing to a change in social policy systems. Methods and analysis Two systems approaches are combined for establishing a systems change in the Netherlands. First, a realist approach enables insights into what in social policy interventions may impact health outcomes, for whom and under what circumstances. Second, an institutional approach enables scaling up these insights, by acknowledging the crucial role of institutional actors for accomplishing a systems change. Together with stakeholders, we perform a realist review of the literature and identify existing promising social policy interventions. Next, we execute mixed-methods realist evaluations of selected social policy interventions in seven municipalities, ranging from small, mid-size to large, and in both urban and rural settings. Simultaneously, through action research with (national) institutional actors, we facilitate development of anticipatory governance strategies. Ethics and dissemination This study is not liable to the Medical Research Involving Subjects Act (WMO). Informed consent to participate in the study is obtained from participants for the use of all forms of personally identifiable data. Dissemination will be codeveloped with target populations and includes communication materials for citizens, education materials for students, workshops, infographics and decision tools for policy-makers and publications for professionals.

administrative requirements (e.g., providing information, attending appointments, and responding to letters and emails) to maintain (full) entitlement to the benefit.

Effects of generosity and eligibility of social benefit systems
Findings of a recent literature review show that widened eligibility and increased generosity of social benefit systems are associated with improved mental health and reduced mental health inequalities (2).Similarly, reduced eligibility and generosity were associated with deteriorated mental health and increased mental health inequalities.These latter findings were in line with findings of a literature review examining the health effect of social assistance programs (3).This review shows that stricter eligibility and generosity result in worse health outcomes.Simpson et al. (2) distinguish mechanisms at two levels that might underly these effects: 1) at the aggregate level (e.g., lower generosity and stricter eligibility criteria coincide with stigmatizing attitudes toward benefit claimants and increased income inequality which may subsequently impair mental health) and 2) at the individual level (e.g., increased generosity and eligibility may hamper employment prospects of claimants which subsequently impair mental health).The direction of the effects of expansionary and contractionary policies on mental health is not straightforward as these policies might trigger mechanisms both improving and harming mental health.The underlying mechanisms are complex and might depend on moderating factors.However, widened eligibility may not improve health in all contexts.In the Netherlands, a randomized experiment among social assistance claimants in The Netherlands shows that imposing a 1-month job search period upon applicants lowered welfare take-up and increased employment rates, while this stricter eligibility regulation did not affect (mental) health (4).

Effects of active labor market policies (ALMPs)
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) A second aspect of social benefits policy that is relevant for health outcomes are Active Labor Market Policies (ALMPs).ALMPs aim to increase re-employment rates and include job search assistance, job or vocational training, and subsidized public and private employment.In general, literature reviews and meta-studies have found that ALMPs have small effects on re-employment in the short run, but larger effects in the medium and long run (e.g., (5,6).Job search assistance programs focusing on 'work first' have similar effects in the short and long run, while job training and private sector employment programs increase employment only in the medium and longer run (probably due to lock in effects).
A literature review about the effects of ALMPs on self-reported health outcomes showed that job search assistance including a psychological component (e.g., enhancing self-efficacy) have positive effects on mental health (7).In general, high-risk groups benefitted most.Effects of vocational training programs and subsidized employment were mostly positive but reflected more diversity.In a recent study using administrative data, Caliendo et al. (8) found that participation in a vocational training program reduced drug prescriptions for cardiovascular and mental health problems by about 6-8 percent, while sickness absence reduced by about 20 percent.This effect was larger for vulnerable groups (e.g., lower educated claimants).Effects were likely to be direct (via adoption of a daily routine) rather than indirect (via improved employment prospects) as the reduction in drugs prescription started when claimants were still enrolled in the training program.
Findings in the Netherlands are generally consistent with international evidence.As found in the Dutch social assistance context, entering paid employment has a positive impact on mental and physical health (9).As a consequence, active labor market policies might act as important health promotion policies among unemployed individuals.In the Dutch social assistance context, welfare departments usually provide employment services (including job search assistance and regular encounters with caseworkers) following a target-group based approach.Schuring et al. (10) investigated the effects of different types of employment service approaches for Dutch social BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2024-088571 :e088571.14 2024; BMJ Open , et al.Van Berkel J assistance claimant using a quasi-experimental approach.They found that Matching (approach focusing on facilitating fast re-employment) reduced drug prescriptions for mental health problems by six percentage points compared to Pre-matching (focus on reducing labor market barriers).These approaches were not significantly different in their impact on other health outcomes (cardiovascular diseases, diabetes, and respiratory illness).Matching also resulted in higher re-employment rates than Pre-matching which might explain the positive finding on mental health.These findings suggest that ALMPs could be important to realize a structural breakthrough in improving mental health among vulnerable individuals.

Effects of requirements, monitoring, and sanction policy
A third aspect of social benefits policy that can affect health outcomes is the enforcement regime.
Economic studies have shown that stricter labor and reintegration requirements, increased monitoring, and more stringent sanction policy tend to decrease unemployment duration and increase job entry rates of (sanctioned) claimants (11)(12)(13)(14), although effects often disappear in the long run and these policies might reduce post-unemployment job quality (15)(16)(17).
Only a few studies investigated the impact of (elements off) the enforcement regime on health outcomes.Some qualitative and correlational studies conducted in the UK suggest that stricter labour and reintegration requirements, monitoring, and sanction policy are predominantly experienced as stressful and punitive and may negatively affect the mental health and well-being of claimants (18)(19)(20).Among claimants of a Danish unemployment benefit program, Baekgaard et al. (21) found that reducing compliance demands to labour and reintegration requirements lowered reported stress levels and increased autonomy.They did not find an effect on stigma.Caliendo et al. (8) investigated the effects of imposed benefit sanctions due to non-compliance to labour and reintegration requirements.They found an increase in drug prescriptions for mental health problems in the month before sanction was imposed (probably due to receiving a warning) and an increase in sickness absence in the months after the sanction was imposed.They did not find a long-run effect BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2024-088571 :e088571.14 2024; BMJ Open , et al.Van Berkel J on drug prescriptions related to cardiovascular diseases and mental health problems.A potential explanation is that negative health effects of being sanctioned due to financial stress might be compensated by a positive health effect via increased re-employment rates.Understanding the mechanisms in the Dutch context would help to design effective policies with positive health effects both in the short and the long run.

Impact of Debt Policy on Health Outcomes
In comparison with studies on social assistance benefits policies, studies investigating the effects of debt policy or interventions on health are scarce.We can distinguish three dimensions of debt policy for potential health outcomes: 1) debt counselling, 2) altering the composition of creditors, and 3) debt restructuring and reduction.In the Netherlands, those dimensions are highly interrelated in debt policy.People who are unable to repay their debts on their own can apply for voluntary or statutory debt restructuring based on the law Wet schuldsanering natuurlijke personen (Wsnp) (translated into Natural Persons Debt Rehabilitation Act).Municipalities appoint debt counsellors who develop a voluntary payment arrangement based on a calculation of how much the debtor can pay to the creditors each month over a period of three years.If the creditors accept the voluntary payment plan, and the debtor adheres to the plan without entering new debts, the remaining debt is acquitted after three years.If the creditors fail to agree to the payment plan, the citizen can apply for statutory debt restructuring.If the application is granted, the judge appoints an administrator who oversees the process and creditors are obliged to agree with the payment plan.Similar to a voluntary plan, after three years of payments, remaining debts are absolved.Despite this apparent protection offered to people with problematic debts under the law, only a fraction (ca.14%) of eligible individuals actually seek assistance (22).To make matters worse, the stabilization process that precedes the voluntary repayment plan often takes months and has a high dropout rate.In addition, municipal approaches are often not well tailored to the complex realities of the lives of BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2024-088571 :e088571.14 2024; BMJ Open , et al.Van Berkel J people with problematic debts, and creditors are not always cooperative.Municipalities differ in the conditions and requirements they impose.For example 20% of the municipalities ask for documentation of the financial situation prior to enrolment, which can be a significant burden for people in problematic debt.It is safe to state that debt policy now fails to reach the large majority of this vulnerable target group, though there are mayor differences between municipalities.

Debt counselling
Of the three dimensions, most evidence is available on the effect of debt counselling on health.A cross-sectional study found that debt counselling significantly reduced financial stressor events among its clients, which in turn was associated with a more positive perception of one's financial situation and perceived health.There were no significant direct effects of debt counselling on perceived health, possible due to the follow-up period of 18 months being too short (23).Similarly, a literature review on the effects of financial counselling shows that there is little evidence for the effect of financial counselling on health.This may be explained by the characteristics of interventions.Most of the interventions that were evaluated put great emphasis on knowledge, while applying behavioural insights might increase the effectiveness of counselling (24).One example of an intervention used in debt counselling that incorporates several behavioural insights is Mobility Mentoring, which was developed by the US-based organization EMPath.Mobility Mentoring has shown promising initial results in the US, but has yet to be proven effective (25).
There is scarce evidence in the Netherlands on the effect of debt counselling on client health.A process evaluation of Mobility Mentoring at a Dutch municipality showed that after six months of assistance, clients reported that their health problems were less hindering for their participation in caretaker, educational or work-related activities.One study compared three types of debt counselling In the Netherlands (26).Intensive support across multiple life domains for clients with complex problems, but also target financial counselling combined with administrative and legal support for relatively self-sufficient clients were both suggested to be successful.Success in BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2024-088571 :e088571.14 2024; BMJ Open , et al.Van Berkel J addressing financial problems coincided with less stress and more belief in a positive outcome in both groups.A counselling type with more limited support accessible for all client types generated less success and less positive health outcomes.Clients experience myriad of emotions, for which there is little attention in the counselling sessions (26).The authors believe that more attention for the client's experience may reduce the attrition rate of debt restructuring trajectories.

Altering the composition of creditors
There is evidence that a smaller number of creditors might have positive health effects.A quasiexperimental study compared households in Singapore that received a certain amount of money to pay off their debts (27).All households received the same amount, which translated into different numbers of creditors that were paid off.Each additional creditor that was paid off was associated with an improved cognitive functioning by a quarter of standard deviation, and 11% less anxiety and 10% less present bias.A qualitative study among UK citizens showed that borrowing from microcredit providers was perceived as having positive effects on health (28).Micro credit reduced stress in the face of unexpected financial costs; it enabled them to maintain social relationships and increased the perceived control over their lives.

Debt restructuring and reduction
In a qualitative study on re-employment among participants of debt restructuring programs, participants reported that the start of the voluntary payment plan led to less mental and physical health complaints, such as stress, sleeping problems, and feelings of depression (29).

GAPS IN KNOWLEDGE
While there are some promising leads for reducing health inequalities through social policy, there is still much to be clarified.As discussed, studies investigating the health effects of debt policies are BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) In addition, there is a lack of studies unravelling the mechanisms underlying the effects of social policies on health outcomes.As a consequence of these gaps, we should be cautious in generalizing the results to the Dutch social assistance benefits context.The present research project aims to fill these gaps for both policy domains.In general, health impacts are usually an unintended by-product of policies that are themselves complex and such effects are embedded and possibly counteracted in a complex system (30).In addition, studies usually fail to account for contextual differences (e.g., rural and urban settings) and to address both ex-ante and ex-post effects of social policies.An approach is necessary that combines evidence on impacts, but that also accounts for the way in which contextual variables interact with policy.
literature reviews on social assistance benefit policies report or show a lack of studies conducted in a Dutch-type welfare context.